23 Pa. C.S. § 5611
I (insert name of designator) do hereby appoint (insert name, address and telephone number of standby guardian) as the standby guardian of (insert name(s) of minor(s)) to take effect upon the occurrence of the following triggering event or events (insert specific triggering events).
I hereby revoke all former wills and codicils to the extent that there is a conflict between those formerly executed documents and this, my duly executed standby guardian designation.
I am the (insert designator's relationship to minor(s)) of (insert name(s) of minor(s)).
(Insert name(s) of minor(s)'s other parent(s)) is the father/mother of (insert name(s) of minor(s)).
His/her address is: _________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
(Check all that apply):
___ He/she died on (insert date of death).
___ His/her parental rights were terminated or relinquished on ( insert date of termination or relinquishment).
___ His/her whereabouts are unknown. I understand that all living parents whose rights have not been terminated must be given notice of this designation pursuant to the Pennsylvania Rules of Civil Procedure or a petition to approve this designation may not be granted by the court.
___ He/she is unwilling and unable to make and carry out day-to-day child-care decisions concerning the minor.
___ He/she consents to this designation and has signed this form below.
By this designation I am granting (insert name of standby guardian) the authority to act for 60 days following the occurrence of the triggering event as a coguardian with me or, in the event of my death, as guardian of my minor child(ren).
Optional: I hereby nominate (insert name, address and telephone number of alternate standby guardian) as the alternate standby guardian to assume the duties of the standby guardian named above in the event the standby guardian is unable or refuses to act as a standby guardian.
If I have indicated more than one triggering event, it is my intent that the triggering event which occurs first shall take precedence. If I have indicated "my death" as the triggering event, it is my intent that the person named in the designation to be standby guardian for my minor child(ren) in the event of my death shall be appointed as guardian of my minor child(ren) when I die.
It is my intention to retain full parental rights to the extent consistent with my condition and to retain the authority to revoke the standby guardianship if I so choose.
This designation is made after careful reflection, while I am of sound mind.
| _______________________________________ | _______________________________________ |
| (Date) | (Designator's signature) |
| _______________________________________ | _______________________________________ |
| (Witness's signature) | (Witness's signature) |
| _______________________________________ | _______________________________________ |
| (Number and Street) | (Number and Street) |
| _______________________________________ | _______________________________________ |
| (City, State and Zip Code) | (City, State and Zip Code) |
If applicable: I (insert name of other parent) hereby consent to this designation.
| _______________________________________ | _______________________________________ |
| (Date) | (Signature of other parent) |
____________________________________________________________________________________
(Address of other parent)
I, (insert name of standby guardian) hereby accept my nomination as standby guardian of (insert minor(s)'s name(s)). I understand that my rights and responsibilities toward the minor child(ren) named above will become effective upon the occurrence of the above-stated triggering event or events. I further understand that in order to continue caring for the child(ren), I must file a petition with the court within 60 days of the occurrence of the triggering event.
| _______________________________________ | _______________________________________ |
| (Date) | (Signature of standby guardian) |
23 Pa.C.S. § 5611